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Please print or type GENERATOR I UNIFORM HAZARDOUS <br />WASTE MANIFEST <br />1 Generator ID Number 2. Page 1 of 3. Emergency Response Phone 4. Manifest Tracking Number <br />I <br />• A j JJK 5 Generator's Name and Mailing Address Generator's Site ... ress (if Oferent than mailing address) <br />Western Express <br />7135 Centennial Place Nashville, TN 37209 15148 N. Thornton Rd <br />Generators Phone: 615-267-9920 - Lodi, CA 95242 <br />Transporter 1 Company Name U.S. EPA ID Number <br />Amon Marine I CAD980737068 Transporter 2 Company Name U.S. EPA ID Number .. ,, . <br />Z .,0 . 2 ) a" IVN fi ; V/ e -OCI ' 7/1/1- /) I e_,AX-te) ,./() /8 <br />Designated Facility Name and Site Address U.S. EPA ID Number <br />Crosby & Overton <br />1630 W. 17th St. - Long Beach, CA 90813 <br />Facility's Phone: (562) 432-544 I CAD02840901P <br />ga. 9b. U.S. DOT Description (including Proper Shipping Name, Hazard Class, ID Number, 10. Containers 11. Total 12. Unit Fim and Packing Group (if any)) No Type Quantity WI.Nol. 13. Waste Codes <br />1 <br />Non-RCRA Hazardous Waste Solid (Diesel, Debris) <br />1 DM 150 p 352 <br />----- - <br />X <br /> <br />NA1993, Combustible Liquid, n.o.s., (Water, Diesel), Comb. <br />Liq., PGlIl 10 DM 500 G 343 <br /> <br /> <br />14. Special Handling Instructions and Additional Information <br />4.--'.' f>0* Z1- 00S -12...t32,,. 1. ERG 171 (1x55) 99611 <br />2, ERG 128 (10x55) 112556 ERO Book In Vehicle: Weer proper <br />, / , 7' ..7-7 <br />OSHA approved PPE When handling he <br />matertats an (Ns manifest JobB 400.13.36394 <br />15 GENERATOR'S/OFFEROR'S CERTIFICATION: thereby declare that the contents of this consignment are fully and accurately described above by the proper shipping name, aid are classified, packaged, <br />rnarked and labeled/placarded. and are in all respects in proper condition for transport according to applicable international and national governmental regulations. If export shipment and I am the Primary <br />Exporter, I certify that the contents of this consignment conform to the terms of the attached EPA Acknowledgment of Consent. <br />I certify that the waste minimization statement identified in 40 CFR 262.27(a) (if I am a large quantity generator) or (b) (ill am a small quantity generator. is true. <br />Gengrator' 0 r's Printed/Typed m Signal r_IA . Day Year, <br />_.1 r—LII 16. International Shipments <br />Import to U.S. Export from U.S. Port of entry/exit: _._ <br />Transporter signature (for exports only): Date leaving U.S.: TRANSPORTER 17. Transporter Acknowledgment of Receipt of Materials <br />Transporter 1 Printed/Typed Name Signa re Month Day Year <br />N It I 1a, I 17 11Q, T <br />NC <br />,---)Si re . <br /> <br />Month Day rei ransporte1r Printed/Ty e m <br />1) e ' Cy 15 4 i6C17Y9 ' A ? 7- - --_-.' • : - - - ''-- ‘ - ....---r----9 I/ gd i?-1 P"' i ...._ )FACILITY 18. umcrepanc; ) <br />Discrepancy Indication Space LII Quantity Type Residue LII Partial Rejection Full Rejection <br />Manifest Reference Number. <br />Alternate Facility (or Generator) U.S. EPA ID Number <br />'acility's Phone. DESIGNATEE f- Signature of Alternate Facility (or Generator) Month Day Year <br />I <br />19. Hazard() s Waste Report Management Method Codes (i.e., codes for hazardous waste treatment, disposal, and recycling systems <br />. \., . 1\ <br />2 <br />,r <br />- / 2 3. 4. <br />n. Designated Facility a wner or Operator: Certification of re ipt of 1. zardous materials covered by the manifest except as tided in Item 18 <br />,rinted/Typed Name Signature <br />\ .._:::.- / _---------\__-• Ir It <br />.... <br />; <br />, Month Day Year <br />/ ,4 <br />/- <br />i 9- 1 x <br />rum ii., nnrn rin,q I VI III rw V VUL.I. VIVID 'IV. LUJV,./VJ <br />orm -Previous editions are obsolete. IGNATED FACILITY TO EPA's e-MANIFEST SYSTar